One in ten US parents opt out of vaccine schedule

Should vaccines be mandatory?

‘The Great Debate: experts explore the balance between freedom of choice and community responsibility’

Most of us have the vaccines our doctors recommend, helping to reduce the risk that we – and those around us – will suffer vaccine-preventable diseases.

But what happens when people opt out?

If you decide not to visit your dentist, choose to eat badly or refuse to wear a helmet while cycling, you put yourself at risk. The direct impact on other people’s health is (pretty much) zero.

With vaccines, the health of your community could be affected. You might catch – and spread – infectious diseases at school, in the workplace or in public places.

If enough people in a community are vaccinated, ‘herd immunity’ can be achieved. This makes it very difficult for infectious diseases to spread because a significant majority of people are protected.

Given that we have a stake in our neighbours’ vaccination status, is it reasonable to insist that everyone have their vaccines? Should it be a condition of accessing education, employment or social payments?

To help understand the issues at play, we sat down with some leading experts and asked whether mandatory vaccination is the answer to minimising the impact of diseases such as measles, diphtheria and pertussis.

Dr Julie Leask of the University of Sydney, says regulation is useful but that absolute mandates go too far. “We need requirements that encourage parents to get their children fully vaccinated,” she says. “But there need to be exemptions for people that don’t vaccinate. It should be harder to get an exemption than to get a vaccine.”

Regulations work, she notes, and help to push the vaccination rates up. However, hard-to-get exemptions are an important component of ‘firm but fair’ policies. Removing other barriers to vaccination, educating health providers and providing strong information systems are also vital pieces of the puzzle.

It’s not all about childhood vaccination. Dr Leask also points to the risk of disease outbreaks resulting from low vaccination rates in adolescents and adults. This, she says, should be part of a multi-part approach to improving public health rather than expecting mandates alone to solve the problem.

Professor Saad Omer, Emory University, takes a similar view. Mandates should, he believes, be used as ‘nudges’. There should be exceptions for those with strong objections but these must be more difficult to secure than the vaccine itself.

“We have shown that there is a reduction in vaccine refusal – and increase in vaccine coverage – if you change the balance of convenience of obtaining exemptions,” he says.

From an ethical perspective, this is the most defendable option, according to Professor Omer: “That strikes the balance between individual autonomy and the community benefit of vaccines.”

Not everyone is so sure that this approach goes far enough. Will appealing to people’s sense of community, and nudging those who are a little hesitant, be sufficient to reach herd immunity (or ‘community immunity’ as it is something known).

Dr Katie Attwell, Murdoch University in Australia, explains why the concept of ‘community immunity’ lacks meaning for people in an individualistic culture.

“The concept of doing things for others has started to break down with the advent of neoliberal ideology, the cult of the individual, and with the idea that if we make decisions about our lives to benefit ourselves we are rewarded,” she says. “It’s very hard to then make claims that when it comes to vaccination you should be looking after other people.”

In addition to this “community deficit”, Dr Attwell says that for some who refuse vaccines, the very idea of herd immunity is open to question. They may not hold a scientific view but, unfortunately, some people remain unconvinced by research.

“Some parents would not see themselves as free-riders benefitting from other people’s decisions to vaccinate,” she explains. “They don’t see that vaccines work, and that what others are doing impacts on their health and wellbeing.”

In light of this, health policymakers have a serious problem: they are pitching the concept of community immunity to individuals whose faith in ‘community’ and ‘immunity’ are strained.

Now what?

Dr Attwell says it’s time to look at all “tools in the toolbox”. These include persuasion, appealing to people’s values, and ensuring vaccines are accessible.

If all of this is in place and vaccination rates are too low, it may become necessary to consider more “coercive” options. The alternative would be to facilitate outbreaks of disease.

Does this mean we should reluctantly embrace vaccine mandates in Europe or would it do more harm than good?